Osteoporosis Screening Guidelines

Vance J. Bray, MD, FACP, FACR

The U.S. Preventive Services Task Force (USPSTF) released guidelines for osteoporosis screening on September 16, 2002. The USPSTF is an independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services. A list of current reviews and recommendations is available at www.ahcpr.gov/clinic/uspstfix.htm.

The USPSTF recommends that women aged 65 and older have routine bone density testing for osteoporosis screening. Routine bone density screening should be offered to women beginning at age 60 if there are additional risk factors for osteoporosis. Utilizing an osteoporosis risk assessment instrument, the task force found low body weight (< 70 kg) and lack of estrogen use to be the most appropriate clinical risk factors for initiating a screening bone density test in women less than 65 years. There is no recommendation either for or against screening postmenopausal women under age 60 or women under age 65 without additional risk factors. The panel also noted that screening women at lower risk for osteoporosis might be able to identify women eligible for treatment but that treatment would only prevent a small number of fractures. It felt that the balance of benefits and harms of screening and treatment for the lower risk population is too close to make a general recommendation. The potential harms of screening include adverse effects of medications and increased anxiety and fears among patients diagnosed with low bone mass.
The USPSTF reviewed osteoporosis prevalence in various populations and the number needed to screen to prevent a particular fracture. The task force found women aged 65-69 are 5.9-fold more likely to have osteoporosis compared to women aged 50-54 and the likelihood is 14.3 fold higher in women aged 75-79. The prevalence of osteoporosis in Mexican-American women is similar to Caucasian women, while African-American women on average have higher bone mineral density. The benefits of treating osteoporosis are greater in women at higher risk for fracture than in women at lower risk. Based on estimates from recent studies the panel estimated the number of fractures that would be prevented over 5 years from screening and treating hypothetical cohorts of patients. For women aged 55-59 years 4,338 women would need to be screened to prevent 1 hip fracture and 1,338 to prevent 1 vertebral fracture. The number needed to screen to prevent 1 hip fracture decreases to 1,856 for women aged 60-64, 731 for women aged 65-69, and 143 for women aged 75-79. The presence of additional risk factors decreases the number needed to screen to prevent a fracture. If a risk factor increases the risk of osteoporosis by 100 percent and the risk of fracture by 70%, 1,092 women aged 60-64 would need to be screened, and 72 treated, to prevent 1 hip fracture.
The USPSTF concluded that: 1) Sufficient evidence exists that the risk for osteoporosis and fracture increases with age, 2) bone density measurements accurately predict the risk of fractures for the short-term, 3) treatment reduces the risk of fracture, 4) a minimum of 2 years may be required between bone density studies due to inherent testing precision limitations.
The USPSTF recommendations for bone density screening can be compared to those of other professional societies. The National Osteoporosis Foundation (NOF) recommends bone density testing for all women aged 65 or older and for all postmenopausal women who have had a fracture or who have one or more risk factors for osteoporosis (www.nof.org/news/pressreleases/guide98.htm). The U.S. National Institutes of Health convened a 2000 Consensus Development Conference that recommended an individualized approach to screening, noting that bone density measurement is appropriate when it will aid the patient’s decision to institute treatment (www.niams.nih.gov/hi/topics/osteoporosis/opbkgr.htm). The World Health Organization convened a round table to discuss osteoporosis screening in September 2000 (www.osteofound.org/advocacy_policy/pdf/gender_equity_roundtable.pdf) and recommended selection of patients for bone density assessment based on strong clinical risk factors. Testing of all women age 65 years or older, all women with a history of fracture not caused by severe trauma, and younger postmenopausal women who have clinical risk factors for fracture (low body weight or family history of spine or hip fracturing) is recommended by the American Association of Clinical Endocrinologists (AACE, www.aace.com/clin/guidelines/osteoporosis2001.pdf ). The American Society for Bone and Mineral Research (ASBMR, www.asbmr.org/Pages/WHI.htm) recommends bone density assessment when HRT is discontinued. The American College of Rheumatology (ACR, www.rheumatology.org/research/guidelines/osteo/osteoupdate.html) recommends obtaining a baseline BMD test when patients are initiating or taking long-term (>6 months) glucocorticoid therapy (prednisone equivalent of 5 mg/day). The International Society for Clinical Densitometry (ISCD, www.iscd.org/patientinfo/index.cfm#who )recommends bone density testing for all women aged 65 and over, all men aged 70 and older, anyone with a fragility fracture, anyone with a disease, condition or medication associated with osteoporosis, anyone considering therapy for osteoporosis, women who have been on hormone replacement therapy for prolonged periods, and anyone being treated for osteoporosis, to monitor effects of therapy. The categories of patients and the endorsements for testing are summarized in table 1.

Society Providing Recommendation

Patient Category

USPSTF

NOF

AACE

ISCD

Women > 65 years of age

Yes

Yes

Yes

Yes

Women aged 60-64 with risk factors

Yes

Yes

Yes

Yes

All women > 65 with risk factors

Yes

Yes

Yes

All women with a fragility fracture

Yes

Yes

Yes

Anyone receiving treatment for OP

Yes

Yes

Men aged > 70 years

Yes

All men with a fragility fracture

Yes

Anyone considering therapy for OP

Yes

Yes

Women on prolonged HRT

Yes

Yes

Anyone with a disease, condition, or medication associated with OP

Yes

In summary, the USPSTF recommends an individualized approach to screening for osteoporosis. There is universal recognition that all women aged 65 and over should have bone density testing and that patients at high risk for osteoporosis and/or fracturing should be referred for testing at a younger age. ISCD wishes to emphasize the importance of bone density testing for the screening of asymptomatic individuals and utilizing BMD testing as a legitimate medical test for the clinical evaluation of patients who have sustained a fragility fracture or have a disease, condition, or medication associated with osteoporosis. Prevention and treatment of osteoporosis should be at the forefront of medical care, with clinicians recognizing readily identifiable clinical risk factors and referring appropriate patients for bone density measurement.

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